A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Reinforce the importance of daily weights.
Call the health care provider for further instructions.
Document the findings and continue with the visit.
Ensure the client has been taking their prescribed diuretic.
The Correct Answer is D
A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.
B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.
C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.
D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is important information to include, as schizophrenia is a chronic condition that often requires ongoing support and resources.
B. Schizophrenia is typically diagnosed in late adolescence or early adulthood, not after 40 years of age.
C. Co-occurring mental health conditions, such as depression or anxiety, are common in individuals with schizophrenia.
D. While individuals with schizophrenia may have a reduced life expectancy, it is not typically as low as 50.2 years of age.
Correct Answer is B
Explanation
A. Medical insurance availability for substance use disorder treatment may affect an individual's ability to access treatment, but it does not directly increase the potential for addiction.
B. Exposure to substances during brain development can alter the structure and function of the brain, making it more susceptible to addiction later in life.
C. While cognitive deficits may contribute to addiction, they are not necessarily a factor that increases the potential for addiction.
D. The age at which an individual begins using substances may affect their risk of addiction, but it is not necessarily a factor that increases the potential for addiction.
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